From the Guidelines
The recommended antiviral therapy for herpes zoster is oral valacyclovir 1000 mg three times daily, oral famciclovir 500 mg three times daily, or oral acyclovir 800 mg five times daily, all for 7 days, while for herpes simplex infections, first-line treatment is oral valacyclovir 1000 mg twice daily for 7-10 days (initial episode) or 5 days (recurrent episodes), or oral acyclovir 400 mg three times daily for the same durations. For herpes zoster, the goal of antiviral therapy is to reduce the severity and duration of symptoms, as well as the risk of postherpetic neuralgia, a common complication in older adults 1. Some key points to consider in the management of herpes zoster and herpes simplex include:
- Starting treatment as soon as possible after symptom onset to maximize effectiveness
- Using oral valacyclovir, famciclovir, or acyclovir as first-line treatments
- Considering pain management with analgesics for herpes zoster, especially in older adults
- For immunocompromised patients or severe cases, intravenous acyclovir may be necessary
- Suppressive therapy with oral acyclovir, valacyclovir, or famciclovir can prevent recurrences of genital herpes, particularly in patients with frequent or severe recurrences 1. The choice of antiviral medication and duration of treatment should be individualized based on the patient's specific needs and circumstances.
From the FDA Drug Label
In subjects aged less than 50 years, the median time to cessation of new lesion formation was 2 days for those treated with VALTREX compared with 3 days for those treated with placebo. The use of VALTREX for treatment of chickenpox in pediatric subjects aged 2 to less than 18 years is based on single‑dose pharmacokinetic and multiple‑dose safety data from an open‑label trial with valacyclovir and supported by safety and extrapolated efficacy data from 3 randomized, double‑blind, placebo‑controlled trials evaluating oral acyclovir in pediatric subjects Famciclovir is approved for the treatment of herpes zoster in adult patients.
The recommended antiviral therapy for herpes zoster is:
- Valacyclovir (VALTREX)
- Famciclovir
The recommended antiviral therapy for herpes simplex is not explicitly stated in the provided drug labels for the treatment of herpes simplex in the specified age groups. However, valacyclovir and famciclovir are used to treat herpes simplex in adults. For pediatric patients, the efficacy and safety of famciclovir have not been established, and valacyclovir may be used for the treatment of chickenpox in pediatric patients aged 2 to less than 18 years 2. Famciclovir is not recommended for the treatment of children 1 to less than 12 years of age with chickenpox or infections due to HSV 3.
From the Research
Antiviral Therapy for Herpes Zoster and Herpes Simplex
The recommended antiviral therapy for herpes zoster and herpes simplex includes:
- Valaciclovir, which is at least as effective as aciclovir in controlling the symptoms of acute herpes zoster 4
- Famciclovir, which is equally effective as valaciclovir in speeding resolution of acute herpes zoster rash and shortening the duration of postherpetic neuralgia 4
- Aciclovir, which can be used for localized disease, but may have limited efficacy due to low oral bioavailability 5, 4
Treatment Regimens
The following treatment regimens are recommended:
- Valaciclovir 1000 mg 3 times daily for 7 days for the treatment of herpes zoster 4
- Aciclovir 800 mg 5 times daily for 7 days for the treatment of herpes zoster 4
- Famciclovir 500 mg 3 times daily for 7 days for the treatment of herpes zoster 4
- Valacyclovir for the treatment of genital herpes, with a once-daily dose of suppressive therapy and a 3-day regimen of episodic treatment of recurrent genital herpes 6
Effectiveness of Antiviral Treatment
Antiviral treatment has been shown to:
- Reduce the intensity of pain and progression of the rash during the acute phase of herpes zoster 7
- Accelerate the healing of the vesicular rash and reduce the duration of viral excretion 7
- Shorten the length and severity of herpes zoster-associated pain and postherpetic neuralgia 8, 6
- Prevent the development of postherpetic neuralgia, although the evidence is not convincing for all authors 7